Prospective study of a panfungal PCR assay followed by sequencing, for the detection of fungal DNA in normally sterile specimens in a clinical setting: a complementary tool in the diagnosis of invasive fungal disease?

We prospectively analyzed 34 clinical biopsy samples from 23 patients with a suspected invasive fungal infection by fungal culture, histology and a panfungal PCR followed by sequencing. Results were compared to the composite diagnosis according the European Organization for Research and Treatment of Cancer (EORTC) criteria. In 34 samples, culture, histology and panfungal PCR were positive in 35%, 38% and 62%, respectively. On the sample level the panfungal PCR revealed a sensitivity of 69% and a specificity of 62.5% compared to proven IFI according postoperative EORTC criteria. On patient level, the sensitivity of the PCR approach was 100%, specificity 62.5%.

[Mitral regurgitation associated with Wegener's granulomatosis]. / Insuffisance mitrale et maladie de Wegener.

BACKGROUND: Wegener's granulomatosis (WG) is a granulomatous disease that can affect many organ systems. The most frequently involved organs include the upper and lower respiratory tract as well as the kidney. Cardiac involvement is rare. METHODS: We report the case of a patient with grade 4 mitral insufficiency associated with severe WG. RESULTS: Surgical analysis of the mitral valve revealed perforation of the anterior leaflet without evidence of endocarditis. Pathological examination of the anterior mitral leaflet revealed myxoid degeneration nodules and bacteriological examination was negative. As the perforated lesion was very close to the free margin of the anterior leaflet, valve replacement appeared a reasonable surgical option in a poor surgical candidate. Six months after the operation, the patient is doing well. CONCLUSION: Wegener's granulomatosis is an autoimmune necrotizing vasculitis that can affect many organ systems. Cardiac involvement is rare. Heart in his globality can be affected by WG in many different ways. Cardiac valvular involvement in WG is rare. The aortic valve seems to be more frequently affected. Cardiologic investigations should have an important place at diagnosis and supervision.

[Late complications of a pseudo aneurysm of the left ventricle: thrombus infection and purulent pericarditis]. / Complications tardives d'un faux anévrisme du ventricule gauche: infection du thrombus et péricardite purulente.

Pseudoaneurysm is a rare complication of left ventricle myocardial infarction. Rupture with tamponade and sudden death is the usual outcome. Surgical intervention remains the treatment of choice. Long term survival cases without surgery are rare. Infection of the thrombus is also a possible event. We report the case of a patient with postinfarction left ventricular pseudoaneurysm complicated by infection of the thrombus and purulent pericarditis involving a peptostreptococcus. Infection must be considered a potential complication of left ventricular pseudoaneurysms.

[Angiosarcoma of the aorta]. / Angiosarcome épithélioïde de l'aorte.

Primary aortic tumors are extremely rare. A 73-year-old woman presented with a 8 kg weight loss associated with abdominal pain. Physical examination was normal. Laboratory tests disclosed increased acute phase reactants. Thoracic and abdominal CT scan showed diffuse splenic and renal hypodense lesions with thrombotic feature of the thoracic aorta extending on 9 cm length. Transesophageal echocardiography showed a large and heterogeneous floating mass advocating a thrombus developed on atheroma. Because of the high risk of embolism the patient underwent surgical replacement of the thoracic aorta. Histopathology revealed an epithelioid angiosarcoma of the aorta. A primary tumor of the aorta should be suspected in the presence of an intra-aortic process presenting features of thrombosis.

Endovascular treatment of thoracic dissection.

Type A aortic dissection remains fatal if untreated. Although classical medical therapy for type B dissection is considered the therapy of choice in uncomplicated cases, the paradigm is changing as greater experience is accrued with endovascular treatments and technical advances improve the long-term outlook. Diagnosis is also becoming more sophisticated, allowing greater appreciation of the anatomy of dissections and improving the knowledge base as their natural history is assessed.

[Endografts (or stent-grafts) and diseases of the descending thoracic aorta]. / Endoprothèses (ou stent-grafts) et pathologies de l'aorte thoracique descendante.

The endovascular treatment of aorta diseases with S-Graft is considered as an alternative to surgery, especially interesting in patients with severe comorbidities. Indeed, the mid-term morbidity and mortality are comparable to surgery in relatively large series, and S-Graft implantation appeared as a safe, less invasive and efficient treatment for different affections of the thoracic aorta. This article reviews technical aspects, indications and results of endovascular repairs of thoracic aorta lesions. We will also assess the advantages and limitations of S-Graft therapy.

Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair.

OBJECTIVE: The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture. METHODS: A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up. RESULTS: In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3. CONCLUSIONS: In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.

[Transhepatic percutaneous embolisation of a post-traumatic pseudoaneurysm of hepatic artery]. / Embolisation transhépatique percutanée d'un pseudoanévrisme post-traumatique de l'artère hépatique.

Pseudoaneurysm of the hepatic artery is a rare complication of blunt abdominal trauma. We report a case of post-traumatic pseudoaneurysm diagnosed several months after the initial traumatism in a 18-year-old man who presented recurrent abdominal pain. This pseudoaneurysm was successfully treated by association of both classical endovascular treatment and transhepatic percutaneous embolization.

[Indication of endovascular stent grafts for traumatic rupture of the thoracic aorta]. / Place des endoprothèses dans le traitement des ruptures traumatiques de l'aorte thoracique.

OBJECTIVE: The usual treatment of traumatic aortic rupture (TAR) is surgical. This invasive technique necessitating thoracotomy and ECC is associated with a mortality rate of more than 20% and a paraplegia risk of about 10%. New minimally-invasive techniques (aortic stent-grafting) are emerging as less risky alternatives to surgery. We report our experience in the percutaneous treatment of TAR with stent-graft via a surgical femoral cut-down. PATIENTS AND METHODS: Between 1996 and 2002, 23 patients (16-65-year-old, mean 36 years) were treated by thoracic stent-grafting. An informed consent was obtained for every patients. Thirteen patients had an acute or sub-acute TAR (1-8 months, mean 5 months) and five patients had chronic TAR (13-24 years, mean 17 years). The technique was done under general anaesthesia and each patient received a preoperative blood-pressure reduction treatment. During the procedure, anticoagulation (heparin) was given and hypotension was induced when the stent-graft was deployed. Direct positioning control was obtained by means of TEE. RESULTS: Eighty percent of patients were extubed immediately after the procedure. Bleeding was <150 ml. The primary success rate was 100% with one minor type 2 endoleak that was spontaneously resolved after 2 months. There was no case of mortality or paraplegia. There were three minor complications (17%), two haematomas at the arteriotomy site and one inflammatory syndrome characterised by slight fever, raised biological markers but with negative blood culture. CONCLUSION: Percutaneous aortic stent-grafting for TAR is a minimally-invasive technique, which constitute an interesting alternative to surgery. It only necessitates a femoral surgical cut-down compared to the thoracotomy and ECC associated with surgery. The complication rate is low and no mortality or major complication was encountered in our patients. Eventually, the long-term follow-up will allow a widening of indications.

[Aortofemoral bypass: gold-standard or outdated?]. / Le pontage aorto-bifémoral: traitement de référence ou intervention du passé?

Although aorto-bifemoral bypass procedures have proven efficacy for the treatment of aortoiliac occlusion, complications have led to a preference for less invasive interventions. A precise knowledge of this morbidity is thus necessary to evaluate and compare outcome with alternative techniques. The purpose of this study was to analyze the course of complications observed in a large group of patients who recently underwent aorto-bifemoral bypass performed by the same team. Between 1975 and 1996, 720 patients underwent aorto-bifemoral bypass procedures for occlusion. Indication for surgery was invalidating claudication in 68%, pain at rest in 28% and trophic disorders in 4%. Mean follow-up was 9.6 years. Twenty-three patients were lost to follow-up. One hundred sixty cases of prosthesis complications were recorded (21.3% of patients): ten infections (1.3%), 14 false aortic aneurysms (2%), 40 false femoral aneurysms (5.5%), 82 prosthetic thrombotic events (11.2%), and 14 femoral anastomotic strictures (1.9%). These complications led to death in nine patients (1.2%) and amputation in 23 (3.2%). Analysis of the results show that late mortality attributable to the prosthesis was minimal compare with other causes of death. Numerous complications occur late after prosthetic repair but their impact on mortality and amputations is limited. Aorto-bifemoral bypass is a safe technique that remains the gold standard for evaluation of other revascularization methods.

A new symmetry-based scoring method for posture assessment: evaluation of the effect of insoles with mineral derivatives.

BACKGROUND: There is a need for a validated rapid procedure for the evaluation of posture, defined as lateral balance/imbalance at the pelvic, shoulder, and neck levels. This would enable clinicians to determine the importance of symmetry in the pathophysiology of musculoskeletal disorders and to assess the efficacy of devices and treatments claiming to normalize or improve posture. In this investigation, the efficacy of such a device, a set of insoles with a hypothesized proprioceptive-like action, was evaluated through use of the described procedure. OBJECTIVES: To develop a new scoring system to evaluate body posture on the basis of symmetry and to use this scoring system to investigate the efficacy of insoles containing a combination of mineral derivatives designed to balance posture through a neurophysiological effect. METHODS: The posture score was based on the evaluation of 4 postural parameters: pelvic and shoulder lateral balance/imbalance, static shoulder rotation, and amplitude of head rotation. In the placebo-controlled study, 32 patients were tested in a double-blind fashion, either with placebo insoles or with insoles containing mineral derivatives. The same study was repeated in unblind conditions in 137 patients selected from 2 chiropractic clinics in an open-label protocol. STUDY DESIGNS: A crossover placebo-controlled, double-blind study and a multicenter, large-scale, open-label study in patients selected from chiropractic clinics. RESULTS: A basal postural evaluation in 137 patients revealed that no patient had a perfect symmetry-ie, a perfectly or nearly perfectly balanced posture. The insoles with mineral derivatives induced a highly significant and similar improvement in the postural score in both the crossover double-blind study (32 patients; 56.7% improvement) and the open-label study (137 patients; 60.7% improvement, P < 0.001). CONCLUSIONS: All patients tested and selected in chiropractic clinics exhibited asymmetries and postural imbalances according to the newly developed scoring method, and this method was successful in assessing the efficacy of insoles exerting a profound and immediate postural effect through a hypothesized neurophysiological mode of action.

[Minimal craniocerebral trauma]. / Das minimale Schädelhirntrauma.

The patient with mild head injury is the most frequently hospitalised trauma patient. The costs for this treatment are enormous. Guidelines for managing the patients are changing for the last 20 years. Haematoma rates of 10% have been shown with CT scans in prospective studies for patients with GCS 14/15 and normal neurological examination. One out of ten of these patients had to undergo craniotomy. CT scans have shown to reduce costs if done on all patients with mild head injury and discharged with normal findings. Patients with skull fractures and age over 65 years are at higher risk, but not patients with loss of consciousness and post traumatic amnesia. We suggest CT scans on all patients. If a CT scan is not available we recommend to observe the patient for 24 hours in the hospital. If a patient with GCS 15 is to be discharged, an information leaflet with instructions for surveillance at home should be given to the patients and to the care taker.

Clinical applications of the holmium:YAG laser in disorders of the paediatric airway.

OBJECTIVE: The aim of this study was to review the role of the holmium:YAG laser in the management of paediatric airway disorders. METHOD: Twenty-six paediatric patients underwent 42 airway procedures between June 1993 and August 1996 in a tertiary care centre. A case series design was used. OUTCOME MEASURES: Safety, precision, hemostasis, bone-cutting properties, and accessibility of the lesion to the equipment were compared to standard therapies. Postoperative outcomes were then compared to standard therapies. RESULTS: Eight patients underwent correction of choanal atresia or revision, 10 patients underwent functional endoscopic sinus surgery, 3 underwent excision of tracheal granuloma, 2 underwent excision of tracheal web or revisions, 1 underwent excision of subglottic stenosis and bronchial stenosis, 1 underwent excision hemangioma of the tongue, and 1 underwent excision papilloma of the oral cavity. One patient in 42 procedures suffered a surgical complication. Our early success rates are comparable to other series using the carbon dioxide laser or cold instruments. CONCLUSION: The holmium:YAG laser is a safe, effective tool in the treatment of paediatric airway disorders and offers the advantage of a flexible fibre-optic system, good hemostasis, and better bone-cutting characteristics compared to the carbon dioxide laser, which is in widespread clinical use.

Simplified methods for fabricating tissue-supported implant-retained overdentures with retention from a resilient liner.

Resilient denture liner materials can be useful for tissue-supported implant-retained overdentures. They allow physiologic movement of the denture toward the tissues. This article presents a technique that offers several advantages over other methods of fabricating the overdenture with a resilient liner, and of transferring the superstructure: the acrylic resin base and the heat-cured resilient liner material are cured simultaneously; superstructure blockout is performed in the laboratory instead of in the mouth, where blockout is difficult; and direct transfer of the superstructure bar is more accurate and eliminates possible fracture of the duplicated superstructure if formed in die stone.

[Long-term results of aorto-bifemoral prostheses in the surgery for atheromatous stenosis of the aortic bifurcation]. / Résultats à long terme des prothèses aorto-bifémorales dans la chirurgie des sténoses athéromateuses du carrefour aortique. 700 malades suivis pendant 20 ans.

Seven hundred patients operated consecutively by the same surgical team for atheromatous stenosis of the aortic bifurcation were followed up for 20 years with only 5 patients lost to follow-up. There were 94.5% of men with a mean age of 58 years. The operative mortality was 2.7% with few deaths due to true cardiovascular causes (0.7% of patients). The secondary mortality was very high with two main causes: cancer (39% of patients) and cardiovascular diseases (37%). Other causes were responsible for only 24% of deaths. The principal complications of the prostheses were: infection (0.6% of operated patients), thrombosis (6.7%), pseudo-aneurysm of the aorta (1.57%) and pseudo-aneurysm of Scarpa's triangle (4%). The benefits of surgery are unquestionable both on terms of survival, as amputation, bed confinement and invalidity are avoided, and in terms of function, as amputation was avoided in 84% of the 32% of patients in Stages III or IV before surgery. Only 5% of patients were amputed during the observation period. Moreover, 79% of survivors had a good functional result at 15 years. Improvement of results depends on better hygienic measures, systematic screening for high risk cancers and a better management of the arterial disease with early treatment of other arterial diseases (coronary, carotid) in order to reduce postoperative and mostly medium- and long-term cardiovascular mortality.

[Surgical repair of postinfarction left ventricular lesion type I]. / Riparazione chirurgica della lesione postinfartuale di I tipo del ventricolo sinistro.

Left ventricular rupture is the most frequent cause of death following myocardial infarction after ventricular arrhytmias and cardiogenic shock. Under these circumstances, only a prompt diagnosis and urgent surgical treatment can be lifesaving. A review of the literature is made and a simple surgical technique with GRF glue application is presented.

Protection of the spinal cord during surgery of thoraco-abdominal aortic aneurysms.

OBJECTIVE: To assess the risk of ischemic cord injury, we have retrospectively studied the 115 patients who underwent a replacement of the thoracic descending or thoraco-abdominal aorta between January 1980 and December 1994. METHODS: In 72 patients the aortic lesion was located above the diaphragm. The aortic replacement was performed with the aid of extracorporeal circulation in all but 2 patients (97.2%). Only two cases of postoperative paraplegia were observed (2.7%). In 43 patients (10 females and 33 males aged from 26 to 69 years), the occurrence of postoperative paraplegia was considered as a major risk, because of the extension of the aortic lesions (Crawford types I, II and III). Twenty-six patients (60.4%) suffered from chronic dissection and 17 patients had atheromatous aneurysms. Sixteen patients (37.2%) had Marfan syndrome. Twelve patients (27.9%) had already undergone aortic replacement. A preoperative study of the spinal cord vascularization was carried out in 36 patients (83.6%) and the Adamkiewicz artery was visualized in 28 patients (77.8%). In 17 patients (39.5%, group I), the surgical procedure was performed without the aid of extracorporeal circulation. In the remaining 26 patients (60.5%, group II), the surgical procedure was carried out with the aid of cardiopulmonary bypass and profound hypothermic circulatory arrest. Sequential unclamping of the aorta was used in all patients. The cord vascularization was surgically restored in 32 patients (74.4%). When the Adamkiewicz artery was identified, the critical intercostal artery was reimplanted together with the two pairs of adjacent intercostal arteries (25 patients). When the origin of the Adamkiewicz artery remained unknown, the two or three most important patent pairs of intercostal arteries were reimplanted (7 patients). In 8 patients (18.6%) there were no patent intercostal arteries. RESULTS: Hospital mortality accounted for 37.2% (16 patients, including 5 patients with paraplegia). On univariate analysis, extension of the aortic lesions, emergency and redo surgery were the only significant risk factors of mortality (P = 0.05). Cord ischemia was observed in 9 patients (21%): permanent paraplegia in 7 patients (16.2%) and transient medullar disturbance in 2 patients (4.6%). The occurrence of paraplegia was reduced, though not significantly, in group II (16%) vs group I (29%) and in patients with preoperative assessment of the cord vascularization (18% vs 38%). CONCLUSIONS: In our experience: 1) The risk of paraplegia is related to the extension and the type of the aortic lesions. 2) The preoperative study of the medullar vascularization and the use of extracorporeal circulation with deep hypothermia and sequential aortic unclamping, reduce the risk of severe cord ischemia, and 3) Occurrence of postoperative paraplegia depends on several factors and cannot be totally prevented by the surgical technique.

Long-term of patients receiving an aorto-bi-femoral prosthesis for atherosclerotic occlusive disease of the aortic bifurcation.

Over a 14-year period (1975-1989), 547 patients with a mean age of 57 years received an aorto-bi-femoral prosthesis for atherosclerotic occlusive disease (AOD) and underwent regular follow-up over a 13-year period. Immediate post-operative mortality was 2.5% with few deaths due to cardiovascular causes (0.5%). The long-term mortality was significantly elevated at 5 years (10% higher than controls) and at 10 years (16%). These deaths were due to the AOD and its surgical treatment (10%), other cardiovascular disease (30%) and cancer (41%). Approximately 5% of patients required an immediate post-operative, or delayed amputation, compared to 33% which had a threatened limb before the operation. Thrombosis of the prosthesis was relatively rare. At 5 years, 81% of the survivors remained largely improved; at 10 years, 67% and at 13 years, 62%. The benefit of this intervention is therefore unquestionable with regards to the functional state and survival. Also, in avoiding immobility due to the disabling intermittent claudication or amputation, it considerably improves the quality of life which largely compensates for the low mortality rates and subsequent complications of the prosthesis.